Combatting Ageism and Stigma in the Assessment of Alcohol Use Disorder among Older Adults: The Need for Routine Screening in Primary and Emergency Care

According to the WHO, the global population of adults age 60 and older is expected to nearly double from 12% in 2015 to 22% in 2050. Similarly, the WHO estimates that the proportion of adults in Europe age 65 and older will rise from 14% in 2010 to 25% by 2040 [1]. Consistent with these predictions, the U.S. Census Bureau estimates the percentage of Americans age 65 and older will increase from 16% in 2019 to 22% in 2040 [2].  What many health care providers fail to recognize, however, is that increasing numbers of older adults, defined here as individuals age 60 and older,  are expected to develop Alcohol Use Disorder (AUD) [3], defined by the American Psychiatric Association as consistent use of alcohol despite its association with significantly impaired distress or functioning in work, school personal relationships [4]. In fact, while up to 30% of hospitalized older adults are likely to meet criteria for AUD, less than 10% are diagnosed and offered treatment [5]. 

Because AUD among older adults represents a hidden epidemic [6] that is commonly underdiagnosed [3] and untreated [5,6] this article’s purpose is to briefly review the epidemiology and etiology of AUD among older adults, discuss its atypical symptom presentation, identify ageist beliefs and stigma that serve as barriers to diagnosis provide evidence-based recommendations for screening in primary care. The need for appropriate, routine assessment of AUD among older adults is essential [7] as its negative outcomes include increased risk of worsening symptoms of depression, anxiety, hypertension, diabetes [8], osteoporosis, chronic pain, erectile dysfunction urinary incontinence [3] falls that result in hospitalization and traumatic brain injury [9] and motor vehicle accidents, inability to perform activities of daily living, dementia, stroke death [3]. 

Epidemiology and Etiology 

Among older adults who misuse substances, alcohol is the most common [3]. Estimates suggest that 10 to 15% of older adults who present in primary care meet criteria for AUD [10]. In Western nations, estimates suggest that between 6 to 16% of older adult men and 2 to 7% of older adult women, in general, meet criteria for AUD [11]. And experts believe that these prevalence rates will increase as members of the “baby boom” generation, who were more likely to use substances in their youth compared earlier generations [7] continue to age [6]. Identified risk factors for alcohol misuse among older adults include depression, parental history of alcoholism [12] major life changes like retirement and loss of a significant other [3]. Also, note that older adults, who take prescription medications, including benzodiazepines and blood thinners, face increased risk of negative drug-alcohol interactions [3]. 

Diagnostic Challenges including Atypical Symptoms and Ageism 

Various factors compromise the ability of health care professionals to properly assess ultimately treat, AUD among older adults. One limiting factor is the atypical symptom presentation of AUD among older adults [5]; the diagnostic criteria for AUD itself appear focused upon young and middle-aged adults [7]. For example, unlike their younger counterparts, older adults with AUD are more likely to present with increased anxiety, urinary or fecal incontinence, malnutrition, falls, dementia, delirium, depression, poor hygiene worsening of symptoms for diabetes and hypertension [5]. Because older adults are more likely to be retired and socially isolated, they are also significantly less likely to meet the diagnostic criteria for impairment in work and social situations, respectively.  Another diagnostic challenge is that AUD among older adults can be classified as either early- or late-onset [5]. Approximately two thirds of older adults with AUD report that they experienced problems with drinking throughout their lifetime, which represents early-onset AUD. The remaining one third report that they only started having problems with drinking later in life, at age 55 on average, representing late-onset AUD. More men report early-onset AUD than women, who report more late-onset and respond more positively to treatment [5]. 

Unfortunately, the social stigma associated with being labeled as problem drinker appears to serve as a barrier for help seeking among older adults, regardless of early- or late-onset AUD [13]. Similarly, some health care providers are unaware of the increasing prevalence of AUD among older adults, including late-onset AUD hold stigmatizing, ageist beliefs that alcohol misuse occurs almost exclusively among young and middle-aged adults [5]. Still other care providers may avoid making a diagnosis altogether, in response to dismissive, nihilistic beliefs that “older patients have already reached the end of their lives, so what’s the point [5]?”. Also note that some health care providers, caregivers friends and family members of older adults can fall prey to the myth that depression, incontinence cognitive impairment are a normal part of aging, rather than a symptom of some other underlying condition, like AUD [5,7]. To illustrate these barriers to assessment, consider that a 30-year-old woman who passed out at work at 1:00 pm in the afternoon, fell urinated all over the floor is more likely to be seen and assessed for AUD in the emergency department than a 65-year-old retired woman who lives alone, passed out in her living room at 1:00 pm in the afternoon, fell to the floor had a similar episode of urinary incontinence. 

Recommendations 

Although less than 15% of primary care physicians reportedly screen their older adult patients for AUD [14], The Institute of Medicine [15] the Substance Abuse and Mental Health Service Administration (SAMHSA) Treatment Improvement Protocol [3] other experts [7] recommend that older adults receive routine screening for alcohol misuse, across health care settings. Fortunately, a few standardized screening measures for AUD among older adults, endorsed by the SAMHSA Treatment Improvement Protocol [3] are readily available. These instruments include the Alcohol Use Disorders Identification Test (AUDIT) [16] and the Short Michigan Alcoholism Screening Test- Geriatric Version (SMAST-G) [17].

The AUDIT [16] is a free, online, 10 multiple choice question resource available to anyone. It is the most used alcohol screening instrument in the world it demonstrates good psychometric properties with older adults [18]. The SMAST-G [17] is the first screening alcohol use-screening instrument developed specifically for use with older adults. It is comprised of 10 yes/no questions, can only be administered by a health care provider like the AUDIT [16] demonstrates good psychometric properties with older adults. All health care providers, including those in primary care, are encouraged to use both screening measures to routinely assess their older adult patients for AUD [5] the world’s increasing older adult population depends upon it for appropriate diagnosis and treatment.

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